20160962 Ver 1_401 Application_20161016

DUKE ENERGY EXCAVATION PERMIT APPLICATION FORM
20 1 e 9,6
FOR DUKE ENERGY USE ON$
Application Fee $ SecuritP$8ptrsiY$ "
Check # Date Recv'd
Date of Duke Energy Lake Services, applicant and/or contractor on-site inspections Date F1ai
t OCT 6
Date Final Protection/Avoidance Area Markings Field - Verified I
DEQ R RE O
Approved to Start Work By * : &
11
(Print) (Sign)
Date Completion Required Date of Any Approved Extension Initials
Date Passed Closeout Inspection*
Initials
Any Stop Work Orders or SMG ViolaRions*? (check one) ❑Yes ❑No (If Yes, explain in PART V)
Date Deposit Refunded Initials Date Permit Database Updated Initials
* Forward copy of approved application (all pages, plus any attachments that Duke Energy changed) back to applicant
with Approval Letter and highlight any changes. File copies of Approval and Close-out Checklists and any Stop Work
Orders with application.
PART I. - APPLICANT INFORMATION (Please Print)
Name Lie/ C I/Y SS Telephone .[phone]
Lake Address1
3+51 Go✓eYNoles �JA� D• Mailing Address � � 3 RIVe-r 5*y-ce4-
(If different) .5I e -e p y 1' o 11 o to , N Y
l� eAtyov', � C X8037
10S�o
Contractor Company C 1 rl,y��Q "« f R e 4C b No
Contractor Contact Person C k 1 J r G�Sts� Telephone
LAKE LOT INFORMATION J
Lake Y County L-1 q alt� City'De N Ve-r State HC Tax Map NNo.��-
Subdivision CTdV e°X 140 R �s s 1 A M A Lot / Section No. Lot Size SCJ-% � Acres
Are there any Co -Applicants*? (check one) ❑Yes ❑No (If Yes, include names, addresses, phone nos., lot nos., lot
sues in PART V —ADDITIONAL INFORMATION * Co -Applicants exist when the proposed work is being done under a
single application, will be performed by a single contractor as one continuous project and is done to benefit multiple owners /
lease holders of project -front properties within a single development. The check for the application filing fee and security
deposit should be from the party shown as Applicant and not several checks from the Applicant and Co -Applicants.
Do not continue the application until an on-site inspection has been conducted between a Duke Energy Lake Services
Representative (DELSR) and the applicant and/or the excavation contractor. NOTE. Initialfung this portion of the
application by a DELSR in no wary constitutes approval or eminent approval of the excavation or any other lake use
permitting activity.
Date of on-site inspection �' Initials (Duke Energy) (applicant/contractor)
Duke Energy Page 1 of 14 rev 9/19/14
Excavation Program
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application 11 3 l0.docx

DUKE ENERGY EXCAVATION PERMIT APPLICATION FORM
PART II. - DESCRIPTION OF PROJECT
A. BASIC INFO
1. Type of excavation: (check one) �Ncw excavation ❑ Maintenance excavation
2. Purpose of excavation: (check one) KBoat Access Channel ❑ Water Intake Channel
❑ Wastewater Discharge Channel O Other (specify'):
3. Lake user category: (check one)vete OResidential Marina OCommercial Marina
Public OOther (specify):
I bo 0- S
4. Max. Excavation Area Dimensions (ft): Length_ Width Depth
(Note: include additional area dimensions if necessary so response to 41Y below equals mea area dimensions in #4)
5. Volume of Excavated Material (TOTAL for the project): ry� —Cubic yards
6. Type of material removed (applicant determines by field sample if practical): /' L U 4/ ; :5 /
7. Excavation Site "=—A- • 0 6 Acre (s) Disposal Site area: n. D % Acre (s)
8. Total Disturbed Area (including equipment staging area): 0 • % Acre (s)
9. Does the project meet the requirements of the applicable General Permit? (check one) Yes ONo
10. Do you claim title to the disposal area? (check one) lyes ONo
11. Do you claim title to the equipment staging area? (check one) 9(Yes ONo
12. Are there any water -treatment facilities within 50 feet of the proposed excavation area? (check one) OYes Xlo
(If Yes, specify):
13. How will the excavated be trapped and the erosion controlled? (eg see attached erosion control plan and
disposal area design): ?�t' r /�� wilt d t li A-G��i%u� o � �9Y �At-A; t
✓ u
14. Type(s) of excavation equipment to be use&• klA'1�zie- g CAV" r
15. Will wags or wetlands be crossed in transporting equipment to or from the site? (check one) Dyes *0
(Ityes, �1)
16. Will return water re-enter the reservoir? (Check one) OYes >yto ON/A (If Yes, specfy points) ofrr-envy and
show on Excavation Area Drawing) //,
17. Is there an existing facility (e•g. pier') that access is Ding maintained to by conducting the excavation? Yes
(If yes, specify the existing permit number. If No, include a scaled drawing of the propared facility). Permit
18. Total planned duration of the work (Include first equipment mobilization, excavation through final mitigation measures
complete): START (0 / �(� FINISH e T - l ,2—�d16
(Month) (Year) (Month) (Year)
Duke Energy
Pro
Page 2 of 14
rev 9/19/14
Excavation gram
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application 113 10.docx

DUKE ENERGY EXCAVATION PERAUT APPLICATION FORM
PART EL (Continued)
B. PROTECTION / AVOIDANCE AREA DESCRIPTION
Complete the following table including all land areas within and immediately adjoining the disturbed area:
Protection/Avofdance Areas
(check all that apply)
ro •
AAcrease
Identification t
&old /Al or Mideate (Ml
*�
Field ID
Work Area Dwa IOD
a. Marshland, swamp, ponds, beneficial
aquatic vegetation or other potential wetlands (circle all
that apply)
NIA
b. Buffer Zones (spec6 width & source of
requirement)I
t. 1 W; II be— d QIJC N
W f
4L
I
c. Environmental Areas as identified by Duke
Energy
d. Natural Areas as identified by Duke Energy
N
e. Historic properties (specify)
` IJA
E Rare or threatened species (spec6)
Duke Energy Page 4 of 14 rev 9/19/14
Excavation Program
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DUKE ENERGY EXCAVATION PERMIT APPLICATION FORM
Protection/Avoidance Areas
(check all that apply)
Approx.
Acr
Identification Method
Avoid tAl or Mitigate lMl
**
F9 l
Work Area D 9- ID
_g. Buried gas, water, sewer, communications
or electric lines (circle)
A
h. Impact Minimization Zones as identified by
Duke Energy
r /
N I
i. Other areas requiring specific avoidance,
protection or mitigation (spew)
* For "Field ID" column, specify entity or person that performed the identification and how it was physically marked (e.g. Duke Energy (John Doe)/Pink and purple -dotted tape,
Corps of Eng. (John Smith)/ yellow flagging). For "Work Area Dwg ID" column, show the symbol that is used on the drawings to identify the protection/avoidance area
** List and attach mitigation plans
Duke Energy Page 5 of 14
Excavation Program
rev 9/19/14
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DUDE ENERGY EXCAVATION PERMIT APPLICATI©N FORM
C. APPLICANT'S SIGNATUREES_
Comments:
Applicant Name (print) RIG S w t S S
Applicant Signature*
Co -Applicant Name (prim)
Co -Applicant Signature*
Co -Applicant Name (print)
Co -Applicant Signature*
Co -Applicant Name (print)
Co -Applicant Signature*
Co -Applicant Name �pririr)
Co ..Applicant signature
Co -Applicant Name {print)
Co-APPRCaut Signature*
M
Lot# l
430
Date 9111ZOIG
Lot #
Date
Lot #
Date
Lot #
Date
Lot #
.Date
Lot #
D
*peff my signature, the information provided in this application is correct to the best of my knowledF.
BEFORE YOU MAIL THE ""CATION TO DUKE ENERGY LAKE SERVICES ENSURE YOU HAVE:
• QMC ED TM INFO THOROUG Y
• MET ALL REQUIRF� FOR A n APPLICATION (see cover tetter q� application pncl6oge)
• INC11UDED A SINGLE CHECK TO DUKE ENERGY FOR THE APPLICATION FILING FEE AND SECURITY
DEPOSIT
INCLUDED ALL AGENCY PERMITS OR COMMENT LETMS AND RESOLVED AL1, ISSUES RAISED
• INCLUDED ALL REQUIRED DRAWINGS (INCLUDING PROPOSED FACHJT MS), PERMIT # FOR EXISTING
FACHMESS, SURVEYS AND PLANS
• INCLUDED COPIES OF DEEDS AND AUTHORIZATION LETTERS
Dake Energy
Page 6 of 14 rcv 9[19114
Excavation Program
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application 113 10.docx

State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
_.
ISA NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
Division of Water Resources FORM: SSGP 10-2013
[� Application Form
Four copies of the application (including attachments) and the application fee should be sent to:
Division of Water Resources
401 & Buffer Permitting Unit
1650 Mail Service Center
Raleigh, NC 27699-1650
1. Applicant Information [15A NCAC 02H .0502(a)]
1. Owner Information
Name: C� 5
Mailing Address:
yeYNor5-56A+•r4 Dr.
DrNve-V" NC C -7803Z
Telephone Number: Fax Number:
E-mail Address: I X . 1Y e4cleY1. Cow"
2. Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here:
http•//www saw usace army mil/Portals/59/docs/regulatory/regdocs/Permits/SAMPLE AGENT AUTH
ORIZATION FORM.pdf) must be attached if the Agent has signed this application form.
Name: Ch'p jar,Agcs
Company Affiliation: J �0 Ne e
Mailing Address: 6 3 a Y'i c Fig �►
eo,-r-s ,-; u e e cel is
Telephone Number:`tt(0&0 • S 111
E-mail Address: /-P.(. sr q.).4115 C
Person to receive the Certification Approval:
Fax Number: 04- (00 • S^
> Al dd SlVekm . Nc
11. Project Information [15A NCAC 02H .0502(a) & (b)]
1. Attach a vicinity map (i.e. street map) clearly showing the location of the property with
respect to local landmarks such as towns, rivers, and roads.
2. Provide a detailed site plan showing property boundaries and proposed locations of
vegetation clearing, structures (buildings, retaining walls, docks, impervious surfaces,
FORM: SSGP 10-2013 Page 1 of 4

construction access corridors. You may use the diagram provided at the end of this
application form.
3. Attach a photograph of the shoreline/ buffer proposed to be stabilized. (Include a scale of
some sort- a yard stick, shovel handle, etc.)
4. Location of the property (where work is to be conducted)
County: Nearest Town: DeAl V'er
Subdivision name or site address (include phase/lot number): �OYCyiyors S Jg WV
Dire ions to ite- please inclpd ad names and numb rs, lan marks, N
A�;
c �T
✓wl4vrs
Latitude (in decimal degrees) �� Longitude (decimal degrees)S
5. Describe the existing land use or condition of the ite at the time of this application
(residential, undeveloped, etc.): Y f 510OU 1PR I
6. Property size (acres):
7. Lake/ river/ ocean adjacent to property:.
8. Describe proposed work (include discussion as to howtlk�
dening of shoreline has been
avoided, or whyit is necessary): rC L t &Cres S
9. Will work be conducted from land? From water? [V
10. Total amount of disturbance (including all excavation, backfill, rip rap, retaining walls, etc.)
below the normal pool take level/ Normal Water Level in square feet or acres:
//)nI'Y y S/ XIS
11. Total amount of disturbance (including all clearing, backfill, excavation, rip rap, retaining
walls, etc.) above the normal pool lake level/ Normal Water Level and 50 feet land -ward in
square fleet or acres:
12. Please describe the vegetation above the normal pool Jake level/ Norma! Water Level a`�
feet landward to be impacted (number of trees, for instance): ark-554Jee
wet
Owner/Agent's Signature
` Printed Name Date
[15A NCAC 02H .0502(fll
Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 10-2013 Page 2 of 3

Fu
Norma
Sr
Lake
Please approximately sketch the following information on this plan (provide dimensions for each
item, such as 10 ft x 100 ft) *:
1. All proposed vegetation clearing
2. Location of rip rap or fill to be placed above the Full Pond/ Normal Water Level elevation
3. Location of rip rap or fill to be placed below the Full Pond/ Normal Water Level elevation
4. Location of any proposed structures such as buildings, retaining walls, docks, etc.
5.Location of any excavation or dredging below the Full Pond/ Normal Water Level elevation
6. Location of construction access corridors
FORM: SSGP 10-2013 Page 3 of 3

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FINAL PLAN
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LOTS T TNLN)VSH M ..e LOTS SI THROUGH SS
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NOTES:
• A PORTION OF THIS PROPERTY 15 LOCATED IN A 100 YEAR FLOOD PLAIN
• PROPERTY MAY BE SUBJECT TORECORDED OR
AS DESIGNATED BY FIRM PANEL / 3710461400
NE NATE: 8-18-2007
LEGEND:
UNRECORDED RIGHTS OF WAYS OR EASEMENTS
NOT OBSERVED
NOEFFPO
• NO PORTION OF THE RESIDENTIAL STRUCTURE IS IN A FLOOD ZONE. BOUNDARY UNE
• OWNER TO VERIFY ALL SETBACKS AND ZONING
REGULATIONS PRIOR TO ANY PLANNING OR
- SANITARY SEWER LINE
- NATURAL GAS UNE
CONSTRUCTION.
' DIMENSIONS OF ALL IMPROVEMENTS SHOWN ON
THIS PLAT SHOULD NOT BE SCALED OR REUEO
SPERO STATHOPOULOS
UNDERGROUND POWER
UNDERGROUND ���
UNDERGROUND TELEPHONE
UPON FOR DESIGN OR CONSTRUCTION WITHOUT
- WATER UNE
FENCE �E
A FIELD VERIFICATION OF ALL DIMENSIONS.
�(� /C
CP COMPUTE- (UNMARKED)
(UNMARKED)
' DIGITAL COPIES OF THIS FILE ARE FOR REFERENCE
.7 V
R/W AY
ONLY AND MAY NOT BE USED FOR bE51CN WORK.
E/P � EDGE OF PAVEMENT
EDGE OF
• 10' GRAIN, 6t UTILITY EASEMENT MAY EXIST ALONG EACH LOT LINE.
CIL E
• NO USGS MONUMENT FOUND WITHIN 2000' OF SUBJECT PROPERTY. � ^
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BEING LOT 131 OF GOVERNOR'S ISLAND
O 3451 GOVERNOR'S ISLAND DR, DENVER NC
)ATE: 10-9-14 DB: 2454 PG: 314
DB: PG:
SCALE: 1" v 30' PB: F PG: 201
CATAWBA SPRINGS TOWNSHIP
LINCOLN COUNTY, INC
CHUCK POOVEY, PLS #3762
ROBERT DEDMON, PLS #3899
3704 NC HIGHWAY #16 BUSINESS NORTH
P.O. BOX 494 — DENVER, NC 28037
PHONE: [phone]
FAX: [phone]
SEAL
L-3762
AN ACTUAL
THE BEST
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